Select Committee on Health Written Evidence

Evidence submitted by the British Society of Audiology (AUDIO 27)

Whether accurate data on waiting times for audiology services are available

  1.  Audiology services provide:

    —    end-to-end diagnosis and on-going management for about 24 care pathways: 9[9]

    —  concerned with hearing and balance,

    —  for adults and for children.

    —    diagnostic services for other care pathways.

  2.  As part of audiology services hearing aid services have been equipped with modern audiological equipment and given funds to provide one of two patient management systems.

  3.  These systems are used for the whole variety of audiology services and are capable of recording date of referral and do record date and time of any significant patient activity including appointments, assessment and fitting of hearing aids.

  4.  However there are no standards for recording referral or appointment type, no systematic interfaces with NHS systems and there are no standard reports that can be aggregated easily.

  5.  We suggest that, whilst there has been considerable advance in the last year with the data collections that the DH has established, there are:

    —    no "accurate" data available on all the pathways in audiology;

    —    no "accurate" data to enable good strategic planning of services eg differentiation of new referrals, existing patients, existing patients with urgent needs; and

    —    good enough data to show that hearing services are high volume and have long waits.

  Thus the data show that there is a problem but are difficult to use in a strategic planning sense.

Why audiology services appear to lag behind other specialties in respect of waiting times and access and how this can be addressed

  6.  Access is a major element in quality service provision and in many respects audiology services occupy two ends of the spectrum. Newborn hearing screening for instance has improved access to services and reduced social and ethnic inequalities in those services. This has done this through specific commissioning of screening and associated services together with clear quality standards and a commissioning specification for PCTs. Clearly this service does not lag behind other comparable services in the UK or elsewhere. On the other hand cochlear implant services for the profoundly deaf seem to be far less accessible and in some cases have associated long waits that clearly lag those in other specialties.

  7.  However, in terms of adult hearing aid services, such simple comparisons are not easy to make. In many areas of the country reported waiting times are minimal and in others they are simply staggeringly long. Whether this difference relates to the extent to which waiting times for existing patients is variably included in data (by differential referral criteria, or by judging existing patient assessment as repairs) is unclear.

  8.  There are four components of access that need to be considered:

    —    Hearing impairment (deafness) is insidious in its effect, on average hearing impaired people who consult wait 12 years (HTA report, Davis et al in press) before getting a service but only about one in three receive a service. So access needs recognition of the problem (often others recognise before the patient).

    —    A third of people who present at GP surgeries with hearing problems are referred for assessment. There is a need for good referral criteria and clearly GPs are deterred from referring to a system that has long waits.

    —    There are many people who have not formally asked for help who would benefit substantially.

    —    Many other people who would benefit from services are not seeking services due to lack of knowledge or due to the lack of appropriate local services eg this is particularly the case for those people with moderate to severe hearing loss who may have been told in the past that "there is nothing much that we can do for you". Due to lack of formal recall and review arrangements these people and their GPs do not know that advances such as DSP hearing aids, implantable devices and environmental aids may be especially helpful if tailored to their requirements.

  9.  Waiting times are long because the demands on the system are not appropriately understood and taken into account in commissioning services. This is typically the case were prevalence of need outstrip demand eg there are at least 4 million adults whose hearing might be cost effectively improved with hearing aids, 10[10] but only 1.2 million of these use hearing aids (with about 0.3 million hearing aid users having mild hearing loss outside this definition), with about 0.75 million seeing their GP and with 0.25 million being assessed and fitted with hearing aids for the first time each year. Small upward variations in referral could quickly lead to long waits. The demography of hearing impairment means that needs will continue to grow quickly at 1% per year for the next 15 years even with no change in prevalence rate due to the profile of the baby boomers and longer life expectancy. In addition to these factors there are two other features that have added to the demand on the services. These are (1) that Digital Signal Processing (DSP) hearing aids are providing far better outcomes and choice for patients than ever before—meaning that there is greater demand that have grown (2) there has not been a consistent policy about exchanging current analogue hearing aids used by patients for the more successful digital hearing aids. It is clear that this policy is variable and variably applied across the country leading to shorter or longer waiting lists.

  10.  There is no doubt that in terms of workflow that there are not many processes in common across departments and that skill mix is not deployed to make the best use of audiological skills. Good practice needs to be applied in terms of waiting list management and DNAs. Better working practices also need to be adopted in respect of working with ENT consultants as a diagnostic service, so that time is used more effectively. These practices would enable better productivity of staff in hearing aid services.

  11.  In order to provide better access to hearing healthcare consideration should be given to providing a screening, assessment or triage service in primary care. Together with more local accessible hearing services (that could capitalise in NHS Direct and NHS Walk in Centres as well as appropriate use of local authority infrastructure) this would ensure that need is equally met across the country. In order to ensure that waiting times are in line with other services, commissioners need to make robust commissioning arrangements against agreed quality standards with appropriate monitoring arrangements.

Whether the NHS has the capacity to treat the numbers of patients waiting

  12.  If appropriate commissioning and management arrangements were in place it is probable that the NHS might be able to assess and treat the numbers of new patients waiting.

  13.  Under current policies it is unclear whether existing patient care, hearing aid upgrade and hearing reassessment could be undertaken with the current capacity.

  14.  Clearly, there is not enough capacity to treat those who would benefit from services.

Whether enough new audiologists are being trained

  15.  The workforce plans for ENT, audio-vestibular medicine and for audiology show the profiles for each of these workforces that play an increasingly inter dependent part in audiology services. The numbers need to be viewed and planned as a whole for audiology services to benefit the most over the next 10-20 years.

  16.  Graduate training in audiology in the UK is in its infancy and the first graduates are just beginning to take up posts. The indications are that these graduates are of incredibly high quality and could play a huge part in taking audiology forward in terms of leadership, scholarship and clinical practice. Clearly, it would be a big mistake not to train sufficient graduates of this calibre and deploy them.

  17.  However, it is clear that despite the workforce review recommending, for example, employing 200 additional paediatric audiologists to meet the changing service requirement, this has not happened, nor have graduates been recruited in the numbers that were envisaged when graduate courses were set up. This needs to be tackled. There is an additional requirement for assistants and associates to enable more efficient and productive services that are not being provided at the moment.

How great a role the private sector should play in providing audiology services

  18.  The private sector provides a good proportion of hearing aids in the UK to people who pay (about 20% of those who have aids, about a third of these also have NHS hearing aids). The private sector has expanded its services in the UK and there is a reasonable choice of hearing aid on the high street at a variety of prices. The private sector has also been procured to provide services (some places this has been additional capacity, in a few places this has been a replacement) for the NHS. It has done this with outcomes that are on a par overall the same compared with the NHS. Local health economies need to decide what sort of partnership, extent and type, they have with the private sector and ensure that they specify the services, including maintenance, training and audit to good quality standards. If the role is not a quality partnership that is managed then it will not provide good long term services to hearing impaired patients—most of whom need about 12 or 15 years of support post assessment.

British Society of Audiology

January 2007

9   See Do Once and Share-Hearing project report on Back

10   Davis, A, Smith, P, Ferguson, M, Stephens, D, and Gianopoulos, Acceptability, benefit and costs of early screening for hearing disability, HTA 2007 (in press). Back

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